| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
945 |
945 |
$82K |
| D0120 |
Periodic oral evaluation - established patient |
1,324 |
1,321 |
$77K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,058 |
2,051 |
$27K |
| D1120 |
Prophylaxis - child |
602 |
600 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,524 |
1,717 |
$23K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
44 |
26 |
$21K |
| D0274 |
Bitewings - four radiographic images |
878 |
873 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
273 |
273 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
75 |
43 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
51 |
25 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
207 |
204 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
14 |
$1K |
| D1999 |
|
72 |
69 |
$40.00 |